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["附件2："]
["北京市基本医疗保险跨省异地就医医疗费用\n手工报销备案登记表"]
[]
["单位名称（章）："]
["统一社会信用代码（社保登记号)："]
["姓   名",null,null,"性  别",null,null,"险种","□.职工医保\n□.城乡居民医保"]
["人员类别","     □.异地安置退休人员 \n     □.异地长期居住人员\n     □.常驻异地工作人员\n     □.异地转诊人员\n     □.超转人员\n     □.离休人员",{"$nulls":3},"登记类别","□.新增\n□.变更\n    □.取消备案"]
["社会保障号码（身份证号）","\n",{"$nulls":3},"工作单位"]
["参保地       家庭住址",{"$nulls":4},"异地联系地址"]
["联系电话1",{"$nulls":4},"联系电话2"]
["转往省\n（市、区）",null,null,"地区\n(市、州)",null,null,"县（区）"]
["异地定点     医疗机构名称",1,{"$nulls":4},"异地定点        医疗机构等级"]
[]
[null,2]
[]
["异地定点医疗机构1盖章            \n\n\n\n                  ",null,"异地定点医疗机构2盖章",null,null,"异地医疗保险部门盖章\n\n\n\n                        \n                         年   月   日"]
{"$rows_empty":7}
["本市定点\n医疗机构名称",{"$nulls":5},"本市定点     医疗机构代码"]
[]
["本人签字",{"$nulls":4},"填表日期"]
[]
[]
["单位经办人签字",null,null,"联系电话",null,null,"经办日期"]
["社保经办机构："]
["办理日期     年    月    日，自办理备案登记次日起生效。"]
["经办人员：",null,null,"社保经办机构盖章：",null,null," 年  月  日"]

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